Nokea
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next?
- A. Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.
- B. Ask the client to assume a side-lying position with the knees flexed.
- C. Perform massage vigorously at the level of the umbilicus if the fundus feels boggy.
- D. Place the client on a bedpan in case the uterine palpation stimulates the client to void.
Correct Answer: A
Rationale: This technique stabilizes the uterus during fundus assessment, preventing discomfort and ensuring accurate palpation.
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Which action by the nursing student, caring for a child who sustained a head injury from a fall, indicates a need for further teaching?
- A. Forcing fluids
- B. Performing neurological assessments
- C. Keeping the child in a sitting-up position
- D. Keeping the child awake as much as possible
Correct Answer: A
Rationale: A child with a head injury is at risk for increased intracranial pressure (ICP). Forcing fluids may cause fluid overload and increased ICP. Additionally, the nurse should not 'force' the client to do something. Neurological assessments must be performed to monitor for increased ICP. Sitting up will decrease fluid retention in cerebral tissue and promote drainage. Keeping the child awake will assist in accurate evaluation of any cerebral edema that is present and will detect early coma.
A client with a history of chronic lymphocytic leukemia is prescribed prednisone. The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Weight gain.
- C. Hypotension.
- D. Hair loss.
Correct Answer: B
Rationale: Prednisone, a corticosteroid, commonly causes weight gain due to fluid retention and increased appetite.
The nurse is assessing a teenage girl. According to the fi gure below, the nurse should note that the girl has:
- A. Kyphosis.
- B. Arthritis.
- C. Developmental dysplasia of the hip.
- D. Scoliosis.
Correct Answer: D
Rationale: The teenage girl has scoliosis, the lateral deviation of the spine. Kyphosis is noted by a forward curvature of the shoulders. Arthritis is diagnosed by radiographs. Hip dysplasia is noted in older children by pain, but is usually diagnosed before the child walks by noting excessive gluteal folds and limited hip abduction.
The nurse is assessing a client with a suspected hip fracture. Which of the following findings is most likely to be present?
- A. External rotation of the affected leg.
- B. Increased range of motion in the hip.
- C. Absence of pain on weight-bearing.
- D. Symmetrical leg lengths.
Correct Answer: A
Rationale: External rotation of the affected leg is a common sign of a hip fracture due to muscle and bone displacement.
A nurse is counseling a mother with young children after the mother left her abusive husband 6 months ago. The mother says, 'My 6-year-old, Kevin, is starting to act just like his father. I just don't know how to handle this.' Which response by the nurse is most appropriate?
- A. You'll have to limit Kevin's contact with his father.'
- B. Counseling for Kevin would be helpful.'
- C. Most boys outgrow these behaviors.'
- D. Setting limits on his behavior is all you need to do now.'
Correct Answer: B
Rationale: Counseling can help address behavioral issues potentially stemming from trauma or modeling, providing professional support for the child.